Principles and Practice of Stereotactic Radiosurgery (eBook)

Foreword 5
Preface 7
Table of Contents 9
Contributors 14
PART I The Fundamentals 22
1 The History of Stereotactic Radiosurgery 23
The Early Years 23
Acceptance 23
Fractionation 25
Extracranial Radiosurgery 25
Organized Radiosurgery 26
Conclusion 26
References 26
2 Neuroimaging in Radiosurgery Treatment Planning and Follow-up Evaluation 28
Introduction 28
Imaging Modalities 28
Computed Tomography Imaging 28
Magnetic Resonance Imaging 29
CT-MR Image Integration 30
Contrast Administration 30
Positron Emission Tomography and Single-Photon-Emission Computed Tomography 31
Magnetic Resonance Spectroscopy 32
MR Perfusion Imaging 32
MR Diffusion Weighted Imaging 32
Combined Imaging Modality 34
Cerebral Angiography 34
Radiologic Considerations in Radiosurgical Planning 36
Size of the Lesion 36
Critical Neuroanatomic Structures 36
Evaluation of Treatment Effi cacy 36
Malignant Gliomas and Metastatic Disease 37
Benign Lesions: Acoustic Neuroma 38
Trigeminal Neuralgia 38
Arteriovenous Malformations 39
Neuroimaging for Radiation-Associated Secondary Tumors 39
Conclusion 40
References 40
3 Techniques of Stereotactic Radiosurgery 43
Introduction 43
History 43
From Stereotaxis to Radiosurgery 43
Notable Contributors 43
Gamma Knife 44
Target Localization 45
Dose Planning 45
Treatment 45
Linear Accelerator–Based Systems 45
Target Localization 46
Dose Planning 46
Treatment 46
Charged Particle Beam 46
Target Localization 47
Dose Planning 47
Treatment 47
Robot-Assisted Linac Radiosurgery 47
Target Localization 47
Dose Planning 48
Treatment 48
Conclusion 48
References 48
PART II Radiation Biologyand Physics 49
4 The Physics of Stereotactic Radiosurgery 50
Introduction 50
The Radiation Source for Radiosurgery 50
Cobalt-60 50
X-Ray Production in a Linear Accelerator 50
Power Supply 51
Modulator 51
Electron Gun 51
Radiofrequency Source 51
Wave-Guide System 52
Accelerator Tube 52
Bending Magnet 52
Treatment Head 52
A Photon’s Interaction with Matter 53
Photoelectric Absorption 53
Compton Scattering 54
Pair Production 54
Dose and Dosimetry 54
Measurement-Based Dose Calculation 55
Percent Depth Dose 55
Profile or Off-Axis Ratio 56
Output 56
Model-Based Dose Calculation 56
Point Kernel 57
Pencil-Beam Kernel 57
Isodose Line and Dose-Volume Histogram 57
Photon Beam Delivery Systems 58
Gamma Knife 58
Isocentric Linear Accelerator 60
CyberKnife 61
Proton Therapy 61
A Proton’s Interaction with Matter 62
Dose Characteristics in Different Modalities 63
Quality Assurance 63
Common QA 63
Specifi c QA 63
Conclusion 65
References 65
Glossary 66
5 Radiobiological Principles Underlying Stereotactic Radiation Therapy 68
Introduction 68
The Three R’s of Radiobiology: Reoxygenation, Repair, and Repopulation 68
Reoxygenation 68
Repair 69
Accelerated Repopulation 70
How Do These Radiotherapeutic Principles Apply to Stereotactic Radiation Therapy? 71
Malignancies 71
Arteriovenous Malformations 71
Benign Tumors 72
How Many Fractions Should Be Used in Stereotactic Radiation Therapy of Cerebral Malignancies? 72
Is Fractionated Stereotactic Radiotherapy Practical? 73
How to Calculate the Appropriate Multifractioned Dose That Is Biologically Equivalent to a Given Single-Fractioned Dose 73
Conclusion 75
Malignant Tumors 75
Arteriovenous Malformations 75
Benign Tumors 75
References 75
6 Experimental Radiosurgery Models 78
Introduction 78
Experimental Models to Investigate Radiosurgery as a Neurosurgical Tool 78
Experimental Models for Investigations into Effects of Normal Brain Radiosurgery 78
Experimental Models Exploring Strategies to Enhance Tumoricidal Effect of Radiosurgery 80
Radiation Protection and Repair 80
Radiation Potentiation 80
Experimental Models for Functional Brain Radiosurgery 81
Hippocampal Radiosurgery for Epilepsy 81
Thalamic Radiosurgery for Movement Disorders 82
Trigeminal Nerve Radiosurgery for Trigeminal Neuralgia 82
Hypothalamic Radiosurgery for Obesity 83
Future Models of Experimental Radiosurgery 83
References 83
7 Treatment Planning for Stereotactic Radiosurgery 85
Introduction 85
Background on SRS Planning 85
Basic Steps in Developing an SRS Treatment Plan 86
Stereotactic Localization 86
Patient Imaging 87
Registering the Images 88
Contouring Structures 88
Defi ning the Prescription 89
Designing the Treatment Plan 89
Dose Calculation 89
Forward Versus Inverse Planning 90
Evaluation of Plan Quality 90
Gamma Knife 91
Gamma Knife Unit 91
Treatment Planning 92
Inverse Planning 93
Linac-Based SRS with Circular Cones 95
Linac-Based SRS with Micro-Multileaf Collimators 95
Fixed Fields 96
Dynamic Conformal Arcs 96
Intensity-Modulated Fields 96
CyberKnife 96
Beam Characteristics 97
Treatment Sites, Planning Scenarios, and Imaging Requirements 97
The Planning Process 98
Proton SRS 99
Dose Modeling 99
Preplanning Consideration 101
Clinical Treatment Planning 101
Other Considerations 103
Conclusion 104
References 104
Glossary 106
8 Designing, Building and Installing a Stereotactic Radiosurgery Unit 107
Design Principles 107
Major Components and Functions 107
Gamma Knife 107
Linear Accelerator–Based SRS Units 108
CyberKnife 110
Integrated Units 112
Accuracy 113
Shielding Design 113
Radiation Safety Program 114
Installation and Acceptance 114
Service and Maintenance 116
Personnel Training and Qualifications 117
Quality Control, Quality Assurance, and Quality Management 117
Cost and Budget 117
References 118
PART III Stereotactic Radiosurgery Techniques 120
9 Gamma Knife Radiosurgery 121
Historical Review 121
The Evolution of Gamma Knife: Models A, B, and C 121
The Radiosurgery Procedure 123
Application of the Stereotactic Guiding Device 124
Stereotactic Brain Imaging Techniques 124
Stereotactic MRI 124
Stereotactic CT Imaging 125
Stereotactic Angiography 125
Quality Assurance of Images 125
Determination of Target Volume(s) 125
Techniques of Conformal Dose Planning 125
Techniques of Stereotactic Radiation Delivery Using Gamma Knife 125
Long-Term Outcome After Gamma Knife Radiosurgery 126
Radiosurgery for Brain Vascular Malformations 126
AVM Radiosurgery 126
Cavernous Malformation Radiosurgery 126
Radiosurgery for Brain Tumors 128
Vestibular Schwannoma Radiosurgery 128
TUMOR GROWTH CONTROL 128
HEARING PRESERVATION 129
FACIAL NERVE AND TRIGEMINAL NERVE PRESERVATION 129
NEUROFIBROMATOSIS TYPE 2 129
Meningioma Radiosurgery 129
Pituitary Adenoma Radiosurgery 129
Radiosurgery of Glial Tumors 131
MALIGNANT GLIOMAS 131
LOWER-GRADE GLIOMAS 131
Brain Metastases Radiosurgery 132
Radiosurgery for Pineal Gland Tumors 132
Radiosurgery for Skull Base Tumors 133
Non–Acoustic Schwannomas 133
Craniopharyngioma 134
Glomus Tumors 134
Hemangiomas 134
Hemangioblastoma 135
Chordoma and Chondrosarcoma 135
Invasive Skull Base Cancers 135
Radiosurgery for Functional Brain Disorders 135
Trigeminal Neuralgia Radiosurgery 135
Movement Disorder Radiosurgery 136
Radiosurgical Targets for Functional Disorders 136
Gamma Knife Thalamotomy 137
Gamma Knife Pallidotomy 137
Other Functional Targets 137
Conclusion 138
References 138
10 Linear Accelerator Radiosurgery 142
Introduction 142
Linac Radiosurgery Technique 144
Radiosurgery for Benign Tumors 144
Vestibular Schwannomas 144
Meningiomas 146
Radiosurgery for Malignant Tumors 147
Cerebral Metastases 147
Malignant Gliomas 148
Arteriovenous Malformations 149
Patient Selection 149
Stereotactic Image Acquisition 149
Dose Selection 149
Follow-up 150
The University of Florida Experience 150
References 151
11 Proton Beam Radiosurgery: Physical Bases and Clinical Experience 154
Introduction 154
Early History of Proton Radiation 154
Facilities 156
Physical Properties 156
Protons Production and Delivery Systems: Conventional Versus Innovative 157
Radiobiological Considerations 158
Patient Setup 158
Patient Treatment Planning and Simulation 159
Clinical Applications of Proton Beam Therapy 161
Eye Tumors 161
CNS Malignancies 162
Meningiomas 163
Gliomas 164
Arteriovenous Malformations 165
Vestibular Schwannoma 165
Pediatric Tumors 166
Pelvic Cancers 168
Head and Neck Tumors 168
Bronchial Cancer and Esophagus 169
Toxicity 170
Socioeconomic Aspects 171
Conclusion 171
References 171
12 Robotics and Radiosurgery 175
Robotic Basics and History of Use in Medicine and Surgery 175
History 175
Robots in Medicine and Surgery: Neurosurgery 176
Robot Development in Other Fields of Surgery 176
Robot Types 176
Moving Radiation Source 177
Conformal Micro-Multileaf 177
Robotics and Image Guidance 177
Ultrasound Imaging 178
X-ray Imaging 178
Other Imaging Techniques 178
Applications of Robotics to Radiotherapy 178
Radiosurgery: The Gamma Knife 178
Linac and CyberKnife, Single and Multiple Stereotactic Fractions 179
Frameless Head and Spine Radiosurgery 179
Tracking Targets 180
Other Methods for Directing the Beam 180
Robotic Couch 181
Glossary 181
References 181
13 CyberKnife Radiosurgery 183
Image-Guided Robotic Radiosurgery 183
CyberKnife Technology 183
CyberKnife Spinal Radiosurgery 183
Fiducial-Free Tracking 185
CyberKnife Body Radiosurgery 185
CyberKnife Treatment Planning 186
Intracranial Lesions 186
Perioptic Tumors 186
Vestibular Schwannomas 187
Trigeminal Neuralgia 187
Spinal Indications 187
Intrathoracic and Intraabdominal Lesions 188
Future Directions 189
Conclusion 189
References 190
PART IV Treatment of Disease Types 191
14 Brain Metastases 192
Introduction 192
Prognostic Factors 192
Surgery 192
Rationale for Using SRS for Brain Metastases 194
Surgery Versus SRS 195
Treatment of Recurrent Metastatic Disease 195
Radiosurgery with WBRT 196
Radiosurgery Alone 197
Large Institutional/Multi-Institutional Results of SRS Alone 198
Phase II/III Trials of SRS with or Without WBRT 198
Complications Associated with SRS 199
Acute Complications 199
Subacute Complications 199
Chronic Complications 199
Future Directions 199
Conclusion 200
References 200
15 Metastatic Brain Tumors: Surgery Perspective 203
Introduction 203
Patient Selection 203
Treatment Outcome 204
Survival 204
Tumor Local Control and Recurrence 205
Complications 206
Cost Effectiveness 207
Quality of Life 207
Conclusion 208
References 208
16 Brain Metastases: Whole-Brain RadiationTherapy Perspective 210
Introduction 210
Efficacy of WBRT 210
Unsettled Issues 210
Attempts to Improve WBRT 210
Complications of WBRT 211
WBRT in the Treatment of Multiple Brain Metastases 211
WBRT in the Treatment of Single Brain Metastases 212
WBRT for Recurrent Brain Metastases 213
References 214
17 High-Grade Gliomas 216
Introduction 216
Historical Perspective 216
Rationale for Stereotactic Radiosurgery 218
Treatment Planning 219
SRS 219
F-SRT 219
Linac Versus Gamma Knife 220
SRS in the Primary Management of HGGs 221
Single Fraction Stereotactic Radiosurgery for Recurrent HGGs 223
Fractionated Stereotactic Radiotherapy 224
Treatment Toxicities 226
Future Directions in Stereotactic Radiation for Glial Neoplasms 227
Conclusion 227
References 227
18 Malignant Glioma:Chemotherapy Perspective 231
Introduction 231
Obstacles to Drug Therapy of Brain Tumors 231
The Blood-Brain Barrier 231
Concomitant Medications 231
How to Measure Antitumor Activity? 232
Active Agents (Table 18-1) 232
Nitrosoureas 232
Procarbazine 232
The PCV Regimen 232
Temozolomide 233
Primary Treatment of Gliobla stoma 233
Treatment Options (Table 18-2) 234
Anaplastic Astrocytoma 234
Anaplastic Oligoastrocytoma and Oligodendroglioma 234
How to Select Patients for Chemotherapy? 235
RPA Analysis (Table 18-3) 235
Chemotherapy Toxicity and Quality of Life 235
Chemotherapy or Stereotactic Radiosurgery 236
References 237
19 Meningioma 240
Introduction 240
Surgical Considerations 240
Radiation Therapy 241
Stereotactic Radiation 242
Stereotactic Radiosurgery 243
Skull Base Meningiomas–SRS 245
Stereotactic Radiotherapy 245
Skull Base Meningiomas–SRT 246
Intensity-Modulated Radiation Therapy 246
Special Applications of Stereotactic Radiation 247
Optic Sheath 247
Atypical and Malignant Meningiomas 247
Combination of Surgery and Radiosurgery 248
Recommendations 249
Patient Algorithm 249
Procedure and Treatment Planning 250
Complication Avoidance 251
Future Directions 252
References 252
20 Meningioma: Surgery Perspective 256
Introduction 256
Surgical Decision-Making and Techniques 257
Convexity Region 257
Parasagittal Region 257
Sphenoid Wing and Anterior Skull Base 259
Petroclival Region 260
Conclusion 261
References 262
21 Intracranial Meningioma: Fractionated Radiation Therapy Perspective 263
Introduction 263
Epidemiology 263
Etiology 263
Radiation-Induced Meningiomas 263
Number of Patients 263
Histopathology 264
Cell of Origin 264
Tumor Grade 264
Benign (WHO Grade I) 264
Atypical (WHO Grade II) 264
Anaplastic/Malignant (WHO Grade III) 264
Treatment and Outcome 264
Surgery 265
Grade Zero Resection 265
Location and Likelihood of Excision 265
Gross Total Resection Alone 266
Subtotal Resection Alone 266
Radiation Therapy 267
Radiation Therapy: Stereotactic Radiosurgery 267
Stereotactic Radiosurgery: Toxicity 268
Stereotactic Radiosurgery: Cranial Neuropathy 268
Stereotactic Radiosurgery: Edema 269
Radiation Therapy: Fractionated External Beam 269
Primary EBRT 269
Primary EBRT for Optic Nerve Sheath Meningiomas 270
Postoperative EBRT 270
EBRT: Technical Factors 270
EBRT: Dose 270
EBRT: Target Volume 270
EBRT: Toxicity 271
EDEMA 271
COGNITIVE 271
EBRT: Special Circumstances 271
ATYPICAL MENINGIOMAS 271
RECURRENT MENINGIOMAS 272
Comparative Outcome: EBRT Versus SRS 272
Conclusion 272
References 273
22 Meningioma: Systemic Therapy Perspective 277
References 279
23 Acoustic Schwannoma 280
Introduction 280
Treatment Options 280
End Points 280
Rationale for Treatment Alternatives and the Case for Radiosurgery 281
Observation 281
Surgery 281
Radiotherapy 282
The Case for Radiosurgery 283
Treatment Planning 283
Outcomes After Radiosurgery 284
Prognostic Factors Affecting Local Control 284
Complication Avoidance and Management 284
Future Directions 284
References 285
24 Acoustic Neuroma:Surgical Perspective 287
Introduction 287
Conservative Management 287
Surgical Management 287
Facial Nerve Results 288
Hearing Preservation 288
Surgical Approaches 288
Choice of Treatment Method (Radiosurgery Versus Excision) 289
Age and Size 289
Hearing Preservation 290
Choice of Surgical Approach 290
References 291
25 Acoustic Neuromas and Other Benign Tumors: Fractionated Stereotactic Radiotherapy Perspective 292
Introduction 292
Radiobiological Principles of FSR for Late-Responding Tissues 292
Optic Nerve Sheath Meningiomas 292
Acoustic Neuromas 293
Technique 296
Clinical Outcomes 297
Optic Nerve Sheath Meningiomas 297
Other Parasellar Tumors 298
Complex Skull Base Tumors 299
Acoustic Neuromas 300
Conclusion 300
References 300
26 Pituitary Tumors 302
Introduction 302
Historical Perspective 302
Pathophysiology 303
Rationale for Treatment 304
Selection of Patients 305
Clinical Results 306
Treatment Plan 305
Other Tumors in the Pituitary Region 308
Complication Avoidance 309
Future Directions 309
References 310
27 Pituitary Adenomas: Surgery Perspective 312
Introduction 312
Surgical Indications 312
Preoperative Radiographic and Endocrinologic Considerations 312
Surgical Approaches to the Pituitary 312
The Endonasal Transsphenoidal Approach 312
Modifications of the Transsphenoidal Approach 313
Transcranial Surgery for Pituitary Tumors 315
Adjuvant Radiosurgery of Pituitary Tumors Involving the Cavernous Sinus 316
Hypophysopexy: Pituitary Transposition 317
Advantages and Disadvantages of Surgery Compared with Radiosurgery for the Treatment of Pituitary Adenomas 317
References 318
28 Pituitary and Pituitary Region Tumors: Fractionated Radiation Therapy Perspective 320
Introduction 320
Pituitary Adenomas 320
Meningiomas 320
Craniopharyngiomas 321
Clinical Presentation 321
Pituitary Adenomas 321
Meningiomas 321
Craniopharyngiomas 321
Diagnostic Workup and Staging 322
Usual Therapeutic Approaches 323
Radiation Therapy 323
Simulation and Radiotherapy Planning 323
Radiation Therapy Results 325
Pituitary Macroadenomas 325
Growth Hormone–Secreting Adenomas (Acromegaly) 325
Prolactin-Secreting Adenomas 326
Adrenocorticotropic Hormone–Secreting Adenomas (Cushing’s Disease) 326
Meningiomas 327
Craniopharyngiomas 327
Conclusion 327
References 327
29 Pituitary and Pituitary Region Tumors: Medical Therapy Perspective 330
Introduction 330
Diagnosis and Classifi cation 330
Pituitary Tumor Subtypes 330
Prolactinomas 330
Diagnosis 330
Management 330
Corticotroph Adenomas 331
Diagnosis 331
Management 331
Thyrotroph Adenomas 331
Diagnosis 331
Management 331
Somatotroph Adenomas 332
Diagnosis 332
Management 332
Gonadotroph and Clinically Nonfunctional Adenomas 332
Diagnosis 332
Management 333
Conclusion 333
References 333
30 Pediatric Radiosurgery 334
Introduction 334
Gamma Knife Radiosurgery 334
Unique Aspects of Radiosurgery in Children 334
Pediatric Brain Tumors 335
Unique Features of Pediatric Brain Tumors 335
Children’s Brain Tumors Are Different from Those of Adults 335
Children’s Brain Tumors Are Different from Other Childhood Tumors 335
The Pathologic Spectrum of Pediatric Brain Tumors 336
Benign and Malignant Pediatric Brain Tumors 336
Initial Management and Overview of Treatment Options 336
Low-Grade Tumors 336
High-Grade Tumors 338
Case Study 30-1 339
Pediatric Arteriovenous Malformations 339
Case Study 30-2 340
Conclusion 342
References 342
31 Pediatric Brain Tumors: Conformal Radiation Therapy Perspective 344
Introduction 344
Contrasting Fractionated Irradiation and Radiosurgery 344
Medulloblastoma 345
Primary Brain Tumors That Require Focal Irradiation 348
Ependymoma 350
Cognitive Effects 351
Endocrine Effects 351
Conclusion 352
References 352
32 Pediatric Brain Tumors: Chemotherapy Perspective 353
Introduction 353
Ependymoma 353
Low-Grade Glioma 354
Medulloblastoma/Primitive Neuroectodermal Tumor 354
Craniopharyngioma 354
References 355
33 Pineal Region Tumors 357
Introduction 357
Anatomy 357
Pineal Region Tumor Presentation and Natural History 357
Pathology 358
Germ Cell Tumors 358
Nongerminomatous Germ Cell Tumors 358
Pineal Parenchymal Tumor 358
Imaging 359
Management of Pineal Region Tumors 359
The Role of Surgery 359
The Role of Radiation 360
The Role of Radiosurgery 360
Case Study 33-1 361
Case Study 33-2 363
Case Study 33-3 363
Barrow Neurological Institute GKRS Experience 364
Dosimetry 364
Results 364
Conclusion 365
References 365
34 Pineal Region Tumors: Surgery Perspective 367
Introduction 367
Surgical Management: An Overview 367
Stereotactic Biopsy 367
Endoscopic Biopsy 367
Craniotomy for Open Resection 368
Surgical Results by Tumor Histology 368
Benign Pineal Region Tumors 369
Glial Tumors 369
Pineal Parenchymal Tumors 369
Germ Cell Tumors 370
Conclusion 370
References 371
35 Pineal Tumors: Fractionated Radiation Therapy Perspective 373
Introduction 373
Conclusion 376
References 378
36 Pineal Region Tumors: Chemotherapy Perspective 379
Introduction 379
Germ Cell Tumors 379
Pineal Parenchymal Tumors 379
Astrocytic Tumors 379
Treatment 380
Germ Cell Tumors 380
Pineal Parenchymal Tumors 382
Pineoblastomas and Pineal Parenchymal Tumors of Intermediate Differentiation 382
Gliomas of the Pineal Region 383
Conclusion 384
References 384
37 Skull Base Tumors 385
Introduction 385
Anterior Cranial Fossa(Angiofi broma and Esthesioneuroblastoma) 385
Angiofi broma 385
Disease Pathophysiology of Angiofi bromas 385
Treatment Options 385
Patient Selection and Treatment Planning Details for Radiosurgery 386
Experiences and Review of the Literature 386
Esthesioneuroblastoma 386
Disease Pathophysiology of Esthesioneuroblastoma 386
Rationale for Treatment and Alternatives 387
Patient Selection and Treatment Planning Detailsfor Radiosurgery 387
Experiences and Review of the Literature 387
Middle Cranial Fossa Tumor 388
Craniopharyngioma 388
Disease Pathophysiology 388
Rationale for Treatment and Alternatives 388
Patient Selection and Treatment Planning Details for Radiosurgery 388
Experiences and Review of the Literature 388
Posterior Cranial Fossa Tumor 389
Chordomas, Chondromas, and Chondrosarcomas 389
Disease Pathophysiology of Chordoma, Chondroma,and Chondrosarcoma 389
Rationale for Treatment and Alternatives 389
Patient Selection and Treatment Planning Details 390
Experiences and Review of the Literature 390
Glomus Jugulare Tumors 390
Disease Pathophysiology of Glomus Jugulare Tumors 390
Rationale for Treatment and Alternatives 390
Patient Selection for Radiosurgery and Treatment Planning Details 391
Experiences and Review of the Literature 391
Conclusion 392
References 392
38 Skull Base Tumors: Surgery Perspective 395
Introduction 395
Surgical Considerations 395
Trigeminal Schwannoma 396
Glomus Jugulare Tumors 397
Chordoma 397
Chondrosarcoma 398
Esthesioneuroblastoma 399
References 399
39 Skull Base Tumors: Fractionated StereotacticRadiotherapy Perspective 402
Introduction 402
Chordoma and Chondrosarcoma 402
Chordoma: General Features 402
Chondrosarcoma: General Features 402
Standard Treatment of Chordoma and Chondrosarcoma 403
Radiosurgery and Fractionated StereotacticRadiotherapy of Chordoma and Chondrosarcoma 404
Patient Selection 404
Treatment Techniques 404
Treatment Outcomes 405
Conclusion 405
Chemodectoma/Paraganglioma 406
Chemodectoma/Paraganglioma: General Features 406
Standard Treatment 406
Radiosurgery and Fractionated StereotacticRadiotherapy of Chemodectoma 407
Patient Selection 407
Treatment Techniques 408
Treatment Outcome 408
Conclusion 408
References 409
40 Head and Neck Tumors 411
Introduction 411
Nasopharyngeal Carcinoma 411
Local Control After Radiotherapy 411
Conventional Salvage Treatment Options for LocalFailures and Selection Criteria 411
Conventional Salvage Treatment Options 411
Patient Selection Criteria for ConventionalSalvage Treatment 412
Results of Conventional Salvage Treatments 412
Radiosurgery for Local Failures of NPC: The QueenMary Hospital Experience (Case Study 40-1 and Case Study 40-2) 412
Patient Population 412
Case Study 40-1 412
Target Localization 413
Case Study 40-2 413
Radiosurgery Planning and Treatment 414
Tumor Control After Radiosurgery 414
Complications 415
Radiosurgery Treatment Results for Local Failuresof NPC in Other Series 416
Radiosurgery Alone 416
Radiosurgery as a Boost After External Reirradiation 416
Fractionated Stereotactic Radiation 416
Radiosurgery as a Boost Treatment AfterRadiotherapy for Newly Diagnosed NPC 417
Summary and Recommendations 417
Other Head and Neck Tumors 418
References 419
41 Head and Neck Tumors:Surgery Perspective 420
Introduction 420
Conventional Treatment 420
Conventional Treatment Results 420
Stereotactic Radiosurgery 421
Stereotactic Radiosurgery Results 421
Discussion 421
References 422
42 Head and NeckMalignancies:Chemotherapy andRadiation Perspective 423
Introduction 423
Locoregional Control and Overall Survival 423
Concurrent Chemotherapy and Radiation 424
Targeted Therapies as Part of a Combined Modality Strategy 424
Intensity-Modulated Radiation Therapy 425
Altered Fractionation Schedules 425
Challenges of Stereotactic Therapy 426
The Option of Reirradiation 426
Conclusion 427
References 427
43 Spinal Tumors 429
Introduction 429
Development of Stereotactic Spinal Radiosurgery 429
Indications for Spinal Radiosurgery 430
Rationale for Radiosurgical Treatment of Benign Spinal Tumors 430
CyberKnife Stereotactic Radiosurgery System 431
Treatment Procedure 432
Targeting Spinal Lesions with Fiducial Placement 432
Treatment Planning 432
Treatment Delivery 432
Radiosurgical Treatment Parameters 432
Results 434
Benign Tumors 434
Radiosurgical Doses and Fractionation 434
Response of Symptoms to Spinal Radiosurgery 434
Tumor Growth Control 435
Neurologic Deterioration After Radiosurgery 435
Malignant Tumors 435
Radiosurgical Doses and Fractionation 436
Response of Symptoms to Spinal Radiosurgery 436
Complications 436
Conclusion 439
References 439
44 Spine Tumors:Surgery Perspective 441
Introduction 441
Tumor Location 441
Deciding on a Treatment Modality 442
Guidelines for Surgical Decision Making 442
Goals of Therapy 445
Diagnosis 445
Neural Decompression 445
Stabilization 445
Curative Resection and Local Control 446
Pain Control 446
Timing of Combined Therapy 446
Deciding on a Surgical Approach 447
Decompressive Posterior Laminectomy 447
Newer Approaches for Spinal Cord Decompression 447
Anterior Approaches 448
Posterolateral Approaches 448
Combined Anterior and Posterior Approaches 448
En Bloc Spondylectomy 449
Percutaneous Vertebroplasty and Kyphoplasty 449
Conclusion 450
References 450
45Spinal Metastases:Fractionated Radiation Therapy Perspective 453
Introduction 453
Fractionated Versus Single-Session SBRT 453
Published Clinical Results 455
Conclusion 456
References 456
46 Arteriovenous Malformation 457
Introduction 457
AVM Management 457
AVM Radiosurgery 458
Patient Selection 458
Technique 459
Obliteration After Radiosurgery 460
Hemorrhage After Radiosurgery 461
Radiation-Related Complications 461
Repeat AVM Radiosurgery 462
Radiosurgery of Large AVMs 463
Case Study 46-1 463
Radiosurgery-Based AVM Grading System 465
AVM Radiosurgery Comparedwith Microsurgery 466
Mayo Clinic Experience 467
References 467
47 ArteriovenousMalformations: Surgery Perspective 471
Introduction 471
Open Surgery 471
Radiosurgery 472
Multimodality Treatment 473
Conclusion 474
References 475
48 Cerebral ArteriovenousMalformations: Endovascular TherapyPerspective 477
Introduction 477
Formulating a Treatment Strategy 477
Neuroendovascular Therapy 478
Preoperative Embolization 478
Targeted Therapy 479
Pre-Radiosurgery 479
Curative Therapy 481
Palliative Therapy 482
Technique: Preoperative Embolization 482
Goals of Embolization 482
Staging 482
Postoperative Care 485
Complications 485
Conclusion 485
References 485
49 CavernousMalformations and Other Vascular Diseases 488
Intracranial Cavernous Malformations 488
Pathophysiology 488
Epidemiology 488
Molecular Basis 489
Clinical Presentation 489
Radiologic Features 489
Management Options 490
The Role of Radiosurgery 492
Dose Planning Technique for CavernousMalformations Radiosurgery 492
Results of Cavernous Malformations Radiosurgery 492
Radiobiological Considerations 494
Radiosurgery for Other Vascular Abnormalities 496
Dural Arteriovenous Fistulas 496
Vein of Galen Malformations 498
References 498
50 Cerebral CavernousMalformations: Surgical Perspective 500
Introduction 500
Epidemiology 500
Anatomic Distribution 501
Natural History 501
Clinical Presentation 502
Diagnostic Imaging 502
Treatment 504
Microsurgical Treatment of Supratentorial Lesions 504
Microsurgical Treatment of Infratentorial Lesions 505
Radiosurgical Treatment of Cavernous Malformations 506
Brain-Stem Cavernous Malformations 506
Conclusion 507
References 507
51 CavernousMalformations and OtherVascular Abnormalities:Observation-AlonePerspective 509
Introduction 509
Cavernous Malformations 509
Natural History 509
Radiosurgery 510
Observation Versus Radiosurgery 511
Dural Arteriovenous Fistulas 511
Natural History 511
Observation Versus Radiosurgery 512
Hemangioblastoma 512
Natural History 512
Radiosurgery 512
Observation Versus Radiosurgery 512
References 512
52 Trigeminal Neuralgia 515
Introduction 515
Treatment Options 515
Mechanism of GK-SRS Effect 516
Targeting, Dose, and Dose Rate 516
Treatment Response 518
Complications 519
Treatment Options for RecurrentTrigemial Neuralgia 519
Secondary Trigeminal Neuralgia 520
Multiple Sclerosis, Post-Herpetic Neuralgia, andAtypical Facial Pain 520
Conclusion 521
References 521
53 Trigeminal Neuralgia:Surgical Perspective 523
Introduction 523
Glycerol Rhizotomy 523
Technique 523
Results 523
Radiofrequency Rhizotomy 524
Technique 524
Results 524
Balloon Compression 524
Technique 524
Results 524
Microvascular Decompression 525
Technique 525
Results 525
Overview of Treatment Options 526
Conclusion 528
References 528
54 Trigeminal Neuralgia:Medical Management Perspective 530
Introduction 530
Clinical Features 530
Pathophysiology 530
Neuropathic Pain 530
Neuropathic Pain Agents: Overview 530
Antiepileptic Drugs 530
Carbamazepine 530
Oxcarbazepine 531
Gabapentin 531
Lamotrigine 532
Topiramate 532
Pregabalin 532
Phenytoin 532
GABA-Related Agents 532
Baclofen 532
Clonazepam 533
Local Anesthetics 533
Capsaicin 533
Narcotic Agents 533
Oral Agents 533
Fentanyl Patch 533
Conclusion 533
References 534
55 Movement Disorder 535
Introduction 535
Parkinson Disease 535
Radiosurgical Thalamotomy 536
Radiosurgical Pallidotomy 537
Radiosurgical Subthalamotomy 537
Essential Tremor 538
Other Applications of Gamma Knife Procedure 538
Movement Disorder Radiosurgery:Technical Considerations 539
Radiosurgery Team 539
The Radiosurgical Device 539
Magnetic Resonance Imaging and Target Planning 539
Dose Selection 540
Radiosurgery Adverse Events 540
Conclusion 540
References 540
56 Movement Disorders:Deep-Brain Stimulation Perspective 543
Introduction 543
Thalamic DBS VersusRadiosurgical Thalamotomy 543
Thalamic DBS 543
Radiosurgical Thalamotomy 544
Pallidal DBS Versus Radiosurgical Pallidotomy 546
Pallidal DBS 546
Radiosurgical Pallidotomy 547
Subthalamic DBS Versus Radiosurgical Subthalamotomy 548
Subthalamic DBS 548
Radiosurgical Subthalamotomy 549
Conclusion 549
References 549
57 Movement Disorder:Medical Perspective 553
Introduction 553
Parkinson Disease 553
Essential Tremor 555
References 555
58 Psychiatric and Pain Disorders 556
Introduction 556
Radiosurgery and Somatic Pain 556
Radiosurgery and Trigeminal Neuralgia 556
Radiosurgery and Psychiatric Disorders 556
Disease Pathophysiology and Radiosurgical Targeting for Pain and Psychiatric Disorders 556
Pain 557
Obsessive-Compulsive Disorder and Depression 558
Anxiety 559
Treatment Alternatives 559
The Case for Radiosurgery 559
Surgical Treatment Alternatives for Painand Psychosurgeries 560
Open Lesioning 560
Deep-Brain Stimulation and Vagal Nerve Stimulation 560
Microvascular Decompression for Trigeminal Neuralgia 560
Radiosurgical Treatment Dosimetry 560
Outcomes Based on the Type of Radiosurgical Device 561
Radiosurgical Treatment Outcomes 561
Pain: Trigeminal Neuralgia 561
Other Types of Pain 561
Psychiatric Disease: Anxiety and OCD 561
Psychiatric Disease: Depression 562
Complications of Functional Radiosurgery 563
Future Directions 563
Conclusion 563
References 564
59 Intractable Epilepsies 566
Introduction 566
Hypothalamic Hamartomas 567
Mesial Temporal Lobe Epilepsy 568
The “Technical” Questions 569
The Dose Issue 569
Is Radiosurgery a “Neuromodulation Therapy”? 570
The Target Defi nition 570
Patient Selection 570
The Potential Concerns 571
What Are the Current Indications? 571
Conclusion 572
References 572
60 Epilepsy: Surgery Perspective 575
Introduction 575
Focal Resections 575
Temporal Resection 575
Lesionectomy Versus Epilepsy Surgery 577
Extratemporal Resection 578
Hypothalamic Hamartoma 578
Hemispherectomy 579
Corpus Callosotomy 579
Multiple Subpial Transection 579
Vagus Nerve Stimulation 579
Stereotactic Radiosurgery 580
Conclusion 581
References 581
61 Ocular and Orbital Lesions 584
Introduction 584
Technical and Radiophysical Aspects of Intraocular Stereotactic Radiosurgery or Radiotherapy 584
Eye Fixation 584
Treatment Planning 585
Leksell Gamma Knife 585
Linear Accelerator 586
Dosimetry 586
Clinical Aspects 587
Uveal Melanomas 587
Pathophysiology 587
Tumor Location 588
Primary Tumor Diagnosis 588
Treatment Methods 588
Surgical Treatment 588
Radiotherapy 588
Brachytherapy 588
Proton Beam Therapy 588
Heavy Charged Particles Therapy 589
Stereotactic Radiotherapy 589
Radiosurgery 589
Radiosurgery (Personal Experience) 589
Imaging and Treatment Planning 589
Follow-up 590
Local Tumor Response 590
Survival 590
Complications 590
Prognostic Factors 593
Other Aspects of Eye Preservation Methods 593
Trials and Treatment Methods Comparison 594
Treatment Methods Comparison 594
Treatment Decision 594
Retinoblastoma 596
Pathophysiology 596
Diagnosis and Treatment 596
Radiosurgery (Personal Experience) 596
Orbital and Uveal Metastases of Carcinomas 596
Pathophysiology 596
Diagnosis 596
Treatment 596
Brachytherapy 596
Radiotherapy 596
Stereotactic Radiotherapy 596
Radiosurgery 596
Prognosis 596
Ocular and Orbital Malignant Lymphomas and Leukemia Infi ltrates 597
Age-Related Macular Degeneration 597
Pathophysiology 597
Diagnosis 597
Treatment Methods 597
Radiotherapy 597
Proton Beam Therapy 597
Photocoagulation 597
Other Methods 598
Radiosurgery 598
Radiosurgery (Personal Experience) 598
Follow-up 598
Glaucoma 598
Pathophysiology 598
Treatment Methods 598
Conventional Treatment 598
Radiosurgery 599
Conclusion 600
References 600
62 Stereotactic BodyRadiation Therapy 602
Introduction 602
Historical Perspective 603
Radiobiology 603
Radiobiologic Models 603
Tumor Response to SBRT 603
Normal Tissue Response to SBRT 604
Rationale 604
Natural History 604
General 604
Lung Cancer 604
Hepatocellular Carcinoma 604
Pancreatic Cancer 605
Renal Cell Cancer 605
Paraspinal Malignancies 605
Oligo Metastases 605
Clinical Trials 605
Expected Outcomes 605
Alternative Treatments 606
Alternative Radiation Fractionations 606
General 606
Lung Cancer 606
Liver Cancer 606
Metastases 606
Alternative Local Therapies 606
General 606
Lung Cancer 606
Liver Cancer 606
Other Alternative Therapies 607
Immobilization 607
Overview 607
Paraspinal Tumor Immobilization 607
Body Tumor Immobilization 607
Correction for Breathing Motion 607
Treatment Planning 608
Overview 608
Imaging at Simulation 609
Target Volumes 609
Planning 609
Image Guidance 610
Overview 610
Image-Guidance Strategies 611
Two-Dimensional Image Guidance Equipment 611
Orthogonal Imaging 611
Real-Time Tumor Tracking 611
Three-Dimensional Volumetric Image Guidance 612
Ultrasound 612
In-Room CT 612
kV Cone Beam CT 612
MV Cone Beam CT 613
MV Tomotherapy 613
Clinical Outcomes 613
Overview 613
Lung Cancer (Case Study 62-1) 614
Liver Cancer (Case Study 62-2) 616
Paraspinal Malignancies 618
Pancreas Cancer 618
Renal Cell Cancer 619
Prognostic Factors 619
Complications 619
Recognition 619
Liver 619
Luminal Gastrointestinal 620
Lung 620
Other 620
Avoidance/Partial Volume Effects 620
Liver Tolerance 620
Lung Tolerance 621
Luminal Gastrointestinal Tolerance 621
Spinal Cord Tolerance 621
Dose-Volume Tolerance Summary 621
Conclusion 621
References 622
63 Stereotactic Body Radiation Therapy:Fractionated Radiation Therapy Perspective 625
Introduction 625
Standard Dose Fractionated Radiation in Unresectable T1/T2 Lung Cancer 625
Would Dose-Intense Radiation Therapy YieldSuperior Results? 626
Single Dose Versus Fractionated Radiation Therapy 627
What Have We Learned from Mouse Models? 627
Clinical Experience 627
Cost-Effectiveness and Quality of Life 630
Conclusion 630
References 631
64 Stereotactic Body Radiation Therapy: Brachytherapy Perspective 633
Introduction 633
Disease Sites 633
Lung Cancer 633
Liver Tumors 635
Bile Duct Tumors 635
Liver Parenchyma 635
Pancreas 635
Patient Selection, Quality of Life, and Cost-Effectiveness 635
Conclusion 636
References 636
PART V Patient Care and Socioeconomic Issues 637
65 Complications and Managementin Radiosurgery 638
Introduction 638
Defi nitions of Radiation Toxicity 638
Acute Complications of Radiosurgery 638
Early-Delayed Effects of Radiation Toxicity 639
Delayed (Late-Delayed) Effects ofRadiation Toxicity 639
Complications for Common Radiosurgery Indications 639
Brain Metastases 639
Meningiomas 640
Acoustic Schwannoma 642
Arteriovenous Malformations 644
Complication Management 645
Conclusion 647
References 648
66 Cost-Effectiveness and Quality of Life 652
Principles of Economic Appraisal 652
Radiosurgery and Economic Appraisals 653
Gamma Knife Versus Linear Accelerator (VersusProton Radiosurgery) 654
Surgery Versus Radiosurgery for Various Conditions 654
Surgery Versus Radiosurgery for Single Brain Metastasis 654
Surgery Versus Radiosurgery for Arteriovenous Malformations 655
Surgery Versus Radiosurgery for Acoustic Neuroma 656
Conclusion 656
Principles of Quality of Life 656
Quality of Life and Radiosurgery 657
Radiosurgery for High-Grade Glioma and Quality of Life 658
Radiosurgery for Brain Metastases/High-GradeGlioma and Quality of Life 658
Radiosurgery for Acoustic Neuroma andQuality of Life 658
Radiosurgery for Arteriovenous Malformation and Quality of Life 658
Radiosurgery for Trigeminal Neuralgia and Quality of Life 659
Conclusion 659
References 659
67 Regulatory and Reimbursement Aspectsof Radiosurgery 661
Historical Perspective 661
Government Oversight 661
510K Premarket Approval 661
U.S. Nuclear Regulatory Commission 662
Certifi cate of Need 663
Coding 663
Cost of Stereotactic Radiosurgery 664
Payor Mix 665
Medicare Reimbursement 665
The Medicare Patient Perspective 665
Medicaid 667
Insurance and Approvals 667
Conclusion 667
References 668
68 Medicolegal Issues in Stereotactic Radiosurgery 669
Introduction 669
Informed Consent 669
Medical Negligence 671
Standard of Care 671
The Anatomy of a Lawsuit 672
The Complaint 672
The Answer 673
Pleadings and Discovery 673
Arbitration: An Alternative to Trial 673
The Trial 673
Appealing the Verdict 674
Conclusion 674
69 The Semantics of Stereotactic Radiation Therapy 675
Introduction 675
Historical Aspects 675
Radiobiological Considerations 676
Semantics 676
Conclusion 677
References 678
70 Building a Radiosurgery Program 679
Introduction 679
Current Utilization 679
Future Growth of Radiosurgery 679
Program Development 680
Identifi cation of Key Participants 681
Identifi cation of Space 681
Identifi cation of Financial Resources 682
Selection of Hardware/Software 682
Integration of Vendors into the Program 683
Credentialing Physicians 683
Marketing to the Community 683
Issues Involved in Treating Patients 684
Staffing 684
Halo Ring Application 684
Treatment Day Timeline 685
Special Considerations 685
Conclusion 686
References 686
71 Patient Care inStereotactic Radiosurgery 687
Index 696

"Robotics and Radiosurgery (p. 163-164)

Cesare Giorgi and Antonio Cossu

Robotic Basics and History of Use in Medicine and Surgery

Similar to surgery, radiosurgery is rapidly becoming a ? eld of application of robotics. Surgeons are confronted with the limits of their dexterity, endurance, and ability to process large amounts of data while operating. Radiation oncologists are able to plan treatments using large amounts of morphologic and functional data and start using robots to deliver the dose with higher precision. The introduction of automation in these ? elds of medicine has different origins and has occurred at a different pace.

Surgery has entered the Information Age with the advent of modern diagnostic capabilities and computer power. The parallel development of endoscope, operative microscope, microinstruments, and navigators has downsized the operative ? eld and minimized surgical exposure. This has resulted in reduction of morbidity-mortality and shortening of hospital stay. The challenge now consists of the development of humaninstrument interfaces, both motor and sensory, to expand surgical possibilities beyond human capabilities. Radiosurgery faces less demanding tasks consisting of the development of devices that achieve high dose conformity and homogeneity in more complex disease geometries and in possibly moving organs.

History

The term robot is less than a century old and was introduced by playwright Karel Capeck in R.U.R. (Rossum’s Universal Robots). Robota is a Czech word for “slave”; in Capeck’s play, living and intelligent working machines built to free humans from work [1]. The concept is at least as old as our culture; Aristotle, two dozen centuries ago, wrote in The Politics, “There is only one condition in which we can imagine managers not needing subordinates, and masters not needing slaves.

This condition would be that each [inanimate] instrument could do its own work. . . . as if a shuttle should weave of itself, and a plectrum should do its own harp playing” [2]. In the following centuries, skill and imagination have left increasingly complex testimony of the concept of an automaton, not only in Western but also in Islamic culture, where in the 13th century Ibn Ismail Ibn al Razzaz al-Jazari published his Al-jami bain al-lim wal-amal al-na? ? sinat’at al-hiyal (“Treatise on the theory and practice of the mechanical arts”) [3].

Western countries expressed mechanical “creatures” working with increasingly complicated clockwork mechanisms from the 14th century throughout the 17th century, to reach maximal expression with the mechanical wonders that ? ourished at the end the 18th century, when the Swiss inventors Pierre and Henri-Louis Jacquet-Droz created their Automatic Scribe, which could write messages up to 40 characters long, and a robotic woman playing the piano [2].

At the turning of the following century, automation exited the role of exotic curiosity and entered the realm of useful devices. Joseph Jacquard invented a programmable loom, operated by punch cards, and went to mass production [4]. Toward the end of that century, Seward Babbitt created the ? rst robot, consisting of a crane with a gripper to remove ingots from a furnace, the ? rst machine designed to substitute for human work in a hostile environment [5].

Contemporarily, Nikola Tesla manufactured wireless controlled vehicles, and coined the term teleautomatics for his study of robotics. [6]. In the 20th century, the term robotics became popular after publication of Isaac Asimov’s “Runaround” story, which introduced his Laws of Robotics. These laws express the concepts that robots must obey human instructions and protect themselves but never cause harm to human beings directly or through inaction [1].

These fundamentals, more than six decades old, will always stand at the base of any design, particularly of machinery interacting with human life. The introduction of computers had an astounding impact on robot technology in the following decades, starting in 1948 with Norbert Wiener’s concept of cybernetics; communication and control in electronic, mechanical, and biological systems [7]. Programming of robots was the ? rst step, accomplished by George Davol in 1946 by means of a magnetic process recorder, and in 1954 with a computer [8].

Robots made their appearance on a production line of an automobile factory in 1963. The next leap was made by Shakey (so-called because of its jerky motion), the ? rst robot with vision, bump detectors at the base, a TV camera, and triangulating range ? nder capable of interaction with the surroundings. It was the ? rst mobile robot that could claim to reason about its actions [9]. Soon this achievement allowed for eye-hand coordination in assembly robots."